Improving the ACS Triage-Using High Sensitivity TroponinI and Copeptin for Early 'Rule-Out' of AMI.

Rule-out of acute myocardial infarction (AMI) in patients presenting with acute chest pain at the emergency department (ED) is a major challenge across the globe. Patients presenting very early with chest pain may provide a diagnostic challenge even when using a cardiac necrosis specific biomarker, high sensitivity troponin (hs-Tn) as they are elevated at 3-6 h after the symptom onset. Copeptin is a marker of acute hemodynamic stress which is released within few minutes of the occurrence of MI and is elevated immediately at the presentation of patients with AMI. This indicates a complementary pathophysiology and kinetics of these two biomarkers. Hence, we evaluated whether or not a protocol with combined testing of copeptin and hs-TnI at admission in patients presenting with chest pain within 6 h in low to intermediate risk and suspected ACS leads to an earlier diagnosis of AMI and thereby, aids to prevent a higher proportion of major adverse cardiac events than the current standard protocol followed in ED. A total of 148 patients as per the inclusion criterion were recruited for the study. The dual biomarker copeptin and hs-TnI allows a rule-out of AMI at presentation with a sensitivity of 100% and NPV of 99.8%. Hence, the use of dual biomarker in conjunction with clinical assessment may obviate the need for a prolonged stay in the ED and retesting hs-TnI after 2 h (for delta check) in more than two-thirds of the patients. The inclusion of these tests could have an impact on the economic burden of the ED without jeopardizing the outcome for the patient.

DRESS syndrome induced by imatinib.

Drug rash with eosinophilia and systemic symptoms (DRESS syndrome) is a severe, potentially life-threatening drug-induced hypersensitivity reaction characterized by cutaneous eruptions, fever, diffuse lymphadenopathy, along with eosinophilia and elevated liver enzymes. The severity and potential organ damage associated with DRESS mandates withdrawing the offending drug and provide a suitable replacement. We report a 55-year-old man who developed prolonged fever, generalized maculopapular rash and facial edema after 3 weeks of starting imatinib for chronic myeloid leukemia (CML). A diagnosis of DRESS was confirmed by eosinophilia and skin biopsy findings, along with a consistent RegiSCAR score. Imatinib was stopped and he was initiated on low-dose steroids, which led to complete resolution of rash and eosinophilia. A rechallenge with imatinib was positive, and he was switched to dasatinib for further therapy, following which he attained an optimal molecular response. DRESS following imatinib has only been reported in eight patients so far. In this report we summarize the current evidence for managing DRESS and its impact on the treatment of CML.

Myocarditis in admitted patients with dengue fever.

PURPOSE: Cardiac involvement in dengue fever is underdiagnosed due to low index of clinical suspicion and its contribution to hemodynamic instability in severe dengue is not well known. METHODS: A prospective observational study was conducted among admitted patients ≥ 14 years of age having confirmed dengue fever. Patients on medications affecting heart rhythm/rate, pre-existing heart disease and electrolyte abnormalities were excluded. A baseline electrocardiography (ECG), Trop-I and NT-proBNP were done for all patients. The biomarkers were measured using enzyme-linked fluorescent assay and recommended cut-off were used. Patients with elevated biomarkers underwent 2-dimensional echocardiography. Diagnosis of myocarditis was as per European Society of Cardiology (ESC) 2013 criteria. RESULTS: A total of 182 patients were recruited with mean age of 30 ± 12.6 years and 31% were females. Dengue with warning signs was present in 85 (47%) and severe dengue in 60 (33%) patients. ECG abnormalities were observed in 44 (24%) patients, biomarkers were elevated in 27 (15%) patients and 11 (6%) patients had echocardiographic abnormalities. According to ESC 2013 criteria, dengue fever with myocarditis was diagnosed in 13 [7.1% (95% CI 3.4-10.9)] patients. The patients with myocarditis were more likely to have shortness of breath, bleeding manifestations and higher respiratory rate at baseline. Clinical features of fluid overload were more common (69% vs. 1.7%, p < 0.01) and the duration of hospital stay longer in myocarditis group (7 ± 4.3 vs. 4.8 ± 1.9 days, p < 0.01). CONCLUSION: Myocarditis among admitted dengue patients is not uncommon and may lead to increased morbidity.

Imaging of the female urethral diverticulum.

Female urethral diverticulum is a localized out-pouching of the urethra that is becoming increasingly prevalent, but often poses a diagnostic challenge. Traditionally, conventional voiding cystourethrography has been used to make the preoperative diagnosis. With the development of higher-resolution images acquired through ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI), the anatomy and various abnormalities of the female urethra can be better elucidated. This article focuses on the imaging features of female urethral diverticulum, with emphasis on diagnostic pearls, particularly using MRI. Female urethral diverticulum can be best identified by their location in the posterolateral urethra and by their communication with the urethral lumen. Improved imaging techniques combined with increased physician awareness of urethral diverticulum will lead to more prompt and accurate diagnosis of this entity, leading to better treatment of affected patients.

Cord serum and placental tissue iron status in maternal hypoferremia.

Studies on 85 mothers with term infants and 32 mothers with preterm infants revealed that the cord serum and placental tissue iron levels were significantly reduced (P less than 0.001) in the mothers with hypoferremia (serum iron less than or equal to 50 microgram/100 ml). These levels were found to have linear correlations with the maternal serum iron levels, suggesting that the fetus and the placenta extracted iron in amounts proportional to the levels available in the mother. The high serum iron values in cord blood compared to the maternal blood even in the mothers with hypoferremia suggested that the process of active transfer of iron from mother to the fetus was maintained in maternal iron deficiency.

Erythrocytic enzymes and amino acids related to glutamic acid metabolism in childhood hypoproteinemic states.

The erythrocyte enzymes of glutamic acid metabolism (glutaminase I, glutaminase II, glutamic acid decarboxylase, glutamine synthetase, and transaminases) and related amino acids (glutamine, glutamic acid, aspartic acid, alanine, and gamma-aminobutyric acid) were estimated in 69 children with protein-energy malnutrition, 13 with nephrosis, and 10 with Indian childhood cirrhosis. Twenty-one apparently healthy children served as controls. There was a significant increase in the activities of erythrocytic glutaminase I, glutaminase II, glutamic acid decarboxylase, and glutamine synthetase in all the three hypoproteinemic states, while the activities of the transaminases showed a decrease in all the conditions. The concentrations of all the amino acids were significantly increased in both the varieties of protein-energy malnutrition (edematous and nonedematous). In nephrosis and Indian childhood cirrhosis, aspartic acid, alanine, and gamma-aminobutyric acid showed a significant rise. The concentration of glutamic acid was also significantly increased in nephrosis. The observations of the present study suggest an increase in intracellular production of glutamic acid in hypoproteinemia.

Anomalous coronary artery simulating parachute mitral valve.

Anomalous left coronary artery, arising from the pulmonary valve, may produce a clinical and radiologic picture mimicking parachute mitral valve (PMV). The pathogenesis is related to left myocardial hypoxia and consequent fibrosis. The authors report a patient with such involvement of the myocardium and contiguous anterior papillary muscle. The result was fibrous atrophy with consequent physiologic and radiologic abnormalities that occur in PMV because of the absence of this muscle, and superficial resemblance to its characteristic morphology.

Quantitation of T cells in venous blood of healthy neonates.

Quantitation of T Cells in blood is the part of the diagnostic workup for cellular immunity. Specimens of venous blood were collected within 24 hours of birth from 51 healthy, appropriate for gestational age infants. T lymphocytes were identified on the basis of their ability to form rosettes with sheep erythrocytes. The lymphocytes were harvested from peripheral venous blood, which is considered to be more representative of the immune status in the newborn than the cord blood. In the newborn infants the proportion in T cells was found to be considerably diminished in comparison to previously reported values for adults. Preterm infants, especially those with gestational age of 34 wk or less had significantly lower percentage of T cells in their blood as compared with term infants. The proportion of T cells was statistically reduced in infants weighing 2000 g or less in contrast to those weighing 2500 g or more.

Serum, zinc and copper levels in children with protein energy malnutrition.

Serum zinc and copper were measured by atomic absorption spectrophotometry in 58 children (3 months-5 years); of these, 46 children had protein energy malnutrition (PEM), and 12 children served as controls. The levels of serum zinc and copper were found to be significantly low in children with severe malnutrition (grades III and IV PEM). There was a significant positive correlation between serum zinc and height-for-age (r = 0.8809, p < 0.001). Serum copper was found low only in children exhibiting marked linear growth retardation (height-for-age < 85% of the normal). Hypoalbuminemia (serum albumin < 2.5 g/dl), and anemia (hemoglobin < or = 8.0 g/dl) in malnourished children were associated with significant decline in serum zinc and copper levels, respectively.

Biochemical abnormalities in neonatal seizures.

Early diagnosis and appropriate treatment of biochemical abnormalities accompanying neonatal seizures is important for effective seizure control and to avoid further brain damage. The present study was carried out on 35 neonates to determine the frequency of various biochemical abnormalities in neonatal seizures. Diagnostic evaluation included estimation of levels of serum calcium, phosphorus, magnesium, sodium, potassium, zinc, and blood glucose. Two-thirds of the neonates with seizures had biochemical disturbances in their sera. A variety of abnormalities occurred in asphyxiated infants, including hyponatremia, hypoglycemia, hypocalcemia, and hypomagnesemia. Primary metabolic disorders accounted for one-forth of the cases of neonatal seizures, the most common being hypoglycemia, hypoglycemia/hypocalcemia, and hypocalcemia/hyperphosphatemia. Inappropriate intrauterine growth, inadequate feeding, and feeding with cow's milk were the main risk factors for primary metabolic seizures. Hyponatremia was a frequent finding in seizures resulting from brain damage like birth asphyxia, meningitis, and intracranial hemorrhage. No infant had hypernatremia, hyperkalemia, hypokalemia, or low serum zinc.

India's first successful intestinal transplant: the road traveled and the lessons learnt.

Intestinal transplant is a therapeutic challenge not just surgically but also logistically because of the multidisciplinary expertise and resources required. A large proportion of patients who undergo massive bowel resection and develop intestinal failure have poor outcome, because of inability to sustain long-term parenteral nutrition and limited availability of intestinal and multi-visceral transplantation facilities. We report the first successful isolated intestinal transplant from India.

Use of ABO-incompatible grafts in living donor liver transplantation--first report from India.

ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.